Contents of daily care record sheet for the elderly

The core content of a practical daily care record form for the elderly can actually be condensed into four major modules: "basic vital sign data, daily behavioral ability performance, special care needs tracking, and abnormal event documentation." There is no absolutely unified standardized template. It will be flexibly added or deleted based on the elderly's health status and care scenarios (home/institutional/semi-disabled/dementia). Completely copying the unified online template will easily lead to problems such as omissions and too much useless information.

In the past two years, I helped the community nursing home adjust a batch of record forms. At first, I used a unified template issued by my superiors. There were 23 basic items listed. It took caregivers nearly an hour to fill in the record form every day. Later, many people found it troublesome and filled it in blindly, which in turn lost the meaning of the record. Later, we deleted half of the unnecessary entries and used different tables for elderly people with different levels of care. In fact, the accuracy rate was much higher.

As for the vital signs that everyone is most familiar with, there is quite a controversy now: one group advocates that healthy and independent elderly people only need to measure blood pressure and heart rate 1-2 times a week. There is no need to measure blood oxygen and blood sugar every day, but it will give the elderly a psychological hint of "I am not in good health."； The other group believes that as long as the elderly have underlying diseases or are over 80 years old, they should have their blood oxygen measured once a day, especially in autumn and winter when respiratory diseases are most common. A drop in blood oxygen is a life-saving signal. In fact, both statements are correct. Our advice to the station at the time was: Elderly people who can go out for a walk and have no underlying diseases should take fewer tests. Those who are bedridden all year round, have chronic obstructive pulmonary disease or cardiovascular and cerebrovascular diseases should record on a daily basis. There is no need for a hard card to unify the standard. The last time the inn received a healthy Uncle Wang, he didn't take it seriously at first and didn't test his blood oxygen. Then he complained of being tired for three days in a row. The nurse took a test and found that his blood oxygen was only 92. He rushed to the hospital to avoid the problem of pneumonia. Since then, we have added "daily blood oxygen for the elderly with basic diseases" to the required options.

In addition to these tangible values, records of daily behaviors are more likely to be ignored. Instead of asking you to fill in the blank options of "able to take care of yourself/semi-disabled", what you need to remember are the details: For example, when you got up today, did you hold on to the wall and slow down for half a minute? Did you drop rice grains while eating? Do you need help zipping up the toilet? These detailed contents are actually what medical science calls the ADL daily living ability assessment, and many warning signs are hidden here. There used to be a grandfather Li who lived alone. He could usually go downstairs to buy things by himself. For three consecutive days, the nurse noted that he "staggered when he got up and stood holding on to the sofa for 10 seconds before walking away." The family took him for a check-up and found out that he had orthostatic hypotension. He prescribed medication in advance to avoid the risk of falling. This area also has different operating logic: if the institution provides batch care, it usually only records "whether it can be completed independently" to facilitate quick calculation of the level of care. ； For home care, it is more recommended to keep a clear record of the completed status. Even something as seemingly insignificant as "I ate half a bowl less today than yesterday" may be a sign of digestive problems.

The content of special care is more flexible. If you have diabetes, you need to add fasting/postprandial blood sugar and insulin injection dosage. If you have Alzheimer's disease, you need to note whether you have lost control of your mood and whether you can't find a home when you go out. For people who have been bedridden for a long time, you need to note the time of turning over and whether the skin is red. I once met a family member who added "emotional trigger items" to his home record sheet. After recording it for more than half a month, I found that the old man would have a tantrum all night after seeing distant relatives. Later, he reduced these sudden visits, and the old man's sleep quality improved more than a little. What is particularly important to mention here is the medication record. Don’t just tick “already taken”. Be sure to record whether you missed a dose and whether you experienced nausea or dizziness after taking it. Many elderly people will have rejection reactions after taking multiple drugs. If you don’t write them down when they first appear, it will be difficult for doctors to determine where the problem lies later. Of course, there is no need to be too rigid. Some elderly people are particularly disgusted by being watched and write every time they take medicine. You can also wait until they fall asleep before taking notes again, or use circle and cross instead of writing. The first priority is for the elderly not to resist and to persist in memorizing.

I met a very interesting family member before. There was a small sticker column next to the record sheet made for the elderly. The elderly had eaten a lot that day and put a small red flower on it when he went out for a walk. Even the caregiver said that it made him happy just to look at it, and his enthusiasm for recording became much higher.

Another module that people tend to miss is the record of abnormal events. Don’t think that you don’t need to record it if you fall and the skin is not broken. It doesn’t matter if you get a little rash on your mouth after eating a mango. Write down these contents and it will come in handy whether you want to see a doctor or avoid disputes when something goes wrong. There used to be a private nursing home because the old man slipped and squatted while walking the day before. The next day the old man complained of back pain and was found to have a fractured lumbar vertebra. The family said that the nursing home did not notify him in advance and it took several months. If he had made a casual note at that time, there would not have been so much trouble.

To put it bluntly, the nursing record form is essentially a "memo" for the elderly's health. It doesn't need to be too elaborate. If you list more than a dozen complicated items, no one will be willing to fill them in. For home care, you can even put a large white paper on the refrigerator, and just write a few strokes when you think of it. Being able to stick to it and remember it is useful is better than anything else.